INSTRUCTIONS Complete this form as thoroughly as possible, and return with a copy of all your unofficial college transcripts; that is all colleges you have attended, and a copy of your student ID clearly showing your picture and name, (suggested size, zoomed in 200% in a photocopy machine). Make sure to sign your application. Return in person to: MESA Staff East Los Angeles College Main Campus 1301 Monterey Park, CA 91754 MESA Office Building E7, Office 210-B (by the FYE/Adelante Program) Contact Us: (323) 780-6730
MESA Community College Program (CCP) Application Social Security Number: - - Campus/Student ID # First Name: _ Middle (or initial) Last Name: _ Permanent Address: Current Address/Mailing Address (if different): City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone ( ) E-mail: Birth date: / / Gender: 1. Male 2. Female Ethnicity: (1) (2) If you are American Indian or Alaskan Native, what is your Tribal Affiliation Is a language other than English spoken regularly in your home? 1. No 2. Yes If yes, specify _ Residential status? US Citizen Permanent Resident F1 Visa Resident Alien Semester and year first enrolled at this college: / Semester Year Current College Counselor: Total number of college units completed: 0-29 30-60 60+ Current college GPA: Declared Major: Highest level of college math passed? _ Courses currently enrolled in? Intended Transfer College(s): 1. 2. 3. Prospective date of transfer: / Semester Year Previous school(s) attended: High School: Date: College: Dates: College: Dates: Obstacles that may interfere with your education? (check all that apply): Financial need Employment issues Family obligations Knowledge of educational system Exceptional needs (specify below) Are you employed? Yes No If yes, how many hours per week? What is the highest level of education achieved by each of your parents/guardians? (Please indicate by using a letter) Father Mother A. No school/elementary school B. 8 th grade or less C. Some high school D. High School graduate E. Some college/university F. Community college degree G. 4-year college degree H. Professional degree (law, medical, etc) I. MS/MA/MBA/Ph.D. J. Other K. Don t know What type of work have your parents or guardians typically done over the past years or prior to retiring? (Please indicate by using a letter) Father Mother A. Never Employed B. Farm Worker C. Business Administration D. Retail/Sales/Clerical E. Mechanic F. Professional (Doctor, Lawyer, Other Professional) G. Factory Worker H. General Laborer I. Teacher/Professor J. Skilled technician Medical, Educational, Trades K. Engineer/Computer Scientist/Scientist L. Other M. Don t know
STUDENT CONTRACT If you are determined eligible for MESA, you are agreeing to follow the student contract below. FOLLOWING THE STUDENT CONTRACT IS PART OF YOUR ELIGIBILITY REQUIREMENT FOR THE MCCP. Please read the contract through, in order to fully understand what will be expected of you as an active MESA student. What MESA can do for you: Provide advising and counseling Provide academic excellence workshops and tutoring in math, science, and engineering to meet your needs Provide and orientation class designed to help you succeed at East Los Angeles College Assist you with applications for scholarships and fellowships Assist you with obtaining summer, part-time, or full-time research Assist you with all transfer requirement to a four-year university Assist you with securing internships and summer enrichment programs What we need you to do: Understand the importance of getting involved in student organizations for your academic and professional career development Understand that the study of math, science, and engineering requires your education to be your number one priority Develop good study habits (by attending our workshops, tutoring, etc) to improve and maintain your grades Consider volunteering at MESA or in the community Admissions Agreement/Personal Information Release: 1. I will notify MESA of any changes in my name, address, or phone number 2. I agree to follow the suggested educational plan designed by MESA 3. I will participate in mesa activities at least once a month 4. I will notify MESA on my class schedule each semester 5. I will notify MESA if I fall below 2.0 grade point average or drop below 12 units 6. I agree to see my advisor at least once a semester 7. I will participate in Academic Excellence Workshops offered for the classes I take. I give my permission for MESA to give my name, phone number and address to college and employer representatives, and to use my photograph in MESA and college promotional materials. Yes No By applying to the MESA Community College Program, I understand that I give my permission for MESA to obtain information about my performance from colleges and testing agencies, financial aid and other offices to determine eligibility for the MESA program. You may be asked to provide additional information for eligibility determination. I certify that I have provided true and correct information. MCCP Applicant Signature Date If under 18 years of age, signature of Parent or Guardian Date MCCP Counselor Signature Date MCCP Director Signature Date Revised 9/27/10 For use in 2010-2011
Criteria Questionnaire Answer the following questions as complete as possible. Are you a first generation college student? Are you in financial Aid? Are you in EOP&S? Are you AB-540? If Yes, do you have a work permit? Yes No Attach a 450-500 words essay answering the following two prompts: Why do you want to join the MESA Program? What do you think you can contribute to the MESA Program? Please list any Volunteer Activities you have participated in. Please Note If you are requesting a letter of recommendation from the MESA Director, you must submit a personal statement and complete 10 hours of volunteer time here at MESA or at any other school related activity. Your request must be received at least one-week in advance and in written. Also, if you are selected to participate and benefit of the MESA program at ELAC, you agree and commit to: Meet with MESA advisor at least once a semester Maintain a GPA of at least a 2.80 Use the MESA study center and tutors Participate actively in MESA activities and workshops Participate actively in one of the STEM clubs at ELAC Volunteer at MESA or a community activity Apply to at least one scholarship or fellowship per year Participate in t least one professional conference sponsored by MESA, a STEM club, or an ELAC academic department. I certify the above information is correct. Signature Date
Student Name Date Last four digits of SS # Student ID # I certify that I have truthfully answered each of the questions that pertain to the Academic Eligibility for MESA. In addition, I am eligible under the Financially and Educationally Disadvantaged student criteria and have completed an interview with the MESA Director or Counselor to determine if I meet the MESA Community College Program criteria. I understand that I cannot take part in MESA if I do not meet the criteria and/or if I have not answered truthfully to any and all of those questions. Student Signature *Do not sign until your meeting with MESA Director or MESA Counselor/Advisor. Director Signature Date: Revised: 9/7/2016 By: Dr. Rivera